Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, USA.
BMC Med Inform Decis Mak. 2010 Dec 20;10:75. doi: 10.1186/1472-6947-10-75.
Advance directives (AD) may promote preference-concordant care yet are absent in many patients with Chronic Obstructive Pulmonary Disease (COPD). In order to begin to inform AD discussions between clinicians and COPD patients, we constructed a decision tree to estimate the impact of alternative AD decisions on both quality and quantity of life (quality adjusted life years, QALYs).
Two aspects of the AD were considered, Do Not Intubate (DNI; i.e., no invasive mechanical ventilation) and Full Code (i.e., may use invasive mechanical ventilation). Model parameters were based on published estimates. Our model follows hypothetical patients with COPD to evaluate the effect of underlying COPD severity and of hypothetical patient-specific preferences (about long-term institutionalization and complications from invasive mechanical ventilation) on the recommended AD.
Our theoretical model recommends endorsing the Full Code advance directive for patients who do not have strong preferences against having a potential complication from intubation (ETT complications) or being discharged to a long-term ECF. However, our model recommends endorsing the DNI advance directive for patients who do have strong preferences against having potential complications of intubation and are were willing to tradeoff substantial amounts of time alive to avoid ETT complications or permanent institutionalization. Our theoretical model also recommends endorsing the DNI advance directive for patients who have a higher probability of having complications from invasive ventilation (ETT).
Our model suggests that AD decisions are sensitive to patient preferences about long-term institutionalization and potential complications of therapy, particularly in patients with severe COPD. Future work will elicit actual patient preferences about complications of invasive mechanical ventilation, and incorporate our model into a clinical decision support to be used for actual COPD patients facing AD decisions.
预先指示（AD）可能促进与偏好一致的护理，但在许多慢性阻塞性肺疾病（COPD）患者中却没有。为了开始告知临床医生和 COPD 患者进行 AD 讨论，我们构建了一个决策树来估计替代 AD 决策对生活质量和数量（质量调整生命年，QALYs）的影响。
考虑了 AD 的两个方面，即不插管（DNI；即不进行有创机械通气）和全码（即可能使用有创机械通气）。模型参数基于已发表的估计值。我们的模型遵循假设的 COPD 患者，以评估 COPD 严重程度和假设的患者特定偏好（关于长期住院和有创机械通气的并发症）对建议的 AD 的影响。
我们的理论模型建议对那些没有强烈反对因插管而出现潜在并发症（气管插管并发症）或出院至长期 ECF 的患者签署全码预先指示。然而，我们的模型建议对那些有强烈反对因插管而出现潜在并发症的患者签署 DNI 预先指示，并愿意权衡大量的生存时间来避免气管插管并发症或永久性住院。我们的理论模型还建议对那些有更高的发生有创通气并发症风险的患者签署 DNI 预先指示（气管插管）。
我们的模型表明，AD 决策对患者关于长期住院和治疗潜在并发症的偏好敏感，尤其是在严重 COPD 患者中。未来的工作将征集患者对有创机械通气并发症的实际偏好，并将我们的模型纳入临床决策支持系统，用于面临 AD 决策的实际 COPD 患者。
